Montreal Cognitive Assessment (MoCA) Administration and
administer the MoCA is approximately 10 minutes The total possible score is 30 points; a score of 26 or above is considered normal 1 Alternating Trail Making: Administration: The examiner instructs the subject: "Please draw a line, going from a number to a letter in ascending order Begin here [point to (1)] and draw a line from 1 then to A
Montreal Cognitive Assessment (MoCA) Overview for Best
MoCA Scoring •Add up the total points •If the client has less than 12 years of formal education, add one point •A “normal” score is equal to or greater than 26/30 •This test does not try to differential between mild, moderate and severe cognitive impairment •It is much more sensitive for picking up mild cognitive
Montreal Cognitive Assessment (MoCA) Version 81
The MoCA may be administered by anyone who understands and follows the instructions, however, only a health professional with expertise in the cognitive field may interpret the results Time to administer the MoCA is approximately 10 minutes The total possible score is 30 points; a score of 26 or above is considered normal
Montreal Cognitive Assessment (MoCA) Administration and
orientation Time to administer the MoCA is approximately 10 minutes The total possible score is 30 points; a score of 26 or above is considered normal 1 Alternating Trail Making : Administration : The examiner instructs the subject: "Please draw a line, going from a number to a letter in ascending order
The Montreal Cognitive Assessment (MoCA): Concept and
A comprehensive review of studies using the MoCA in multiple clinical settings and populations is provided An algorithm for using the MoCA in clinical practice is suggested In conclusion, MoCA limitations, future research and developments are discussed 2 Cognitive Domains assessed by the MoCA Visuospatial/Executive Modified Trail Making Test
NAME : MONTREAL COGNITIVE ASSESSMENT (MOCA) Education : Date
MONTREAL COGNITIVE ASSESSMENT (MOCA) [ ] Date Month Year Day Place City [ ] Contour [ ] [ ][ ] Numbers [ ] Hands [ ] [ ] [ ] 4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2 pts, 1 correct: 1 pt, 0 correct: 0 pt ( 3 points ) Category cue Points for UNCUED WITH NO CUE recall only Optional
MOCA-Montreal Cognitive Assessment Test Form
MONTREAL COGNITIVE ASSESSMENT (MOCA) Version 7 1 Original Version VISUOSPATIAL / EXECUTIVE FACE NAME : Education : Sex : Date of birth : DATE : POINTS /5 /3 No points —/1 /3 /2 /2 /6 —/30 Copy cube VELVET 1 st trial 2nd trial Subject has to repeat them in the forward order Subject has to repeat them in the backward order
A practical toolkit for clinicians
Abbreviated mental test score (AMTS) 23 6-Item cognitive impairment test (6CIT) 24 General practitioner assessment of cognition (GPCOG) 25 Mini-cog 27 Dementia commissioning for quality and innovation (CQUIN) 28 Addenbrookes cognitve examination-III (ACE-III) 29 Montreal cognitive assessment (MoCA) 38 Other tests 40 Advisory group 41 2 1 3 4 A
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The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad Nasreddine
Version: February 18, 2012
Julayanont, P., Phillips, N., Chertkow, H., and Nasreddine, Z.S. The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review.
To appear in A.J. Larner (Ed.), Cognitive Screening Instruments: A Practical Approach. Springer-Verlag, pp. 111-152. The Montreal Cognitive Assessment (MoCA):
Introduction
The Montreal Cognitive Assessment (MoCA) was developed as a brief screening instrument to detect Mild
Cognitive Impairment.(1) It is a paper-and-pencil tool that requires approximately 10 minutes to administer, and is
scored out of 30 points. The MoCA assesses multiple cognitive domains including attention, concentration,
executive functions, memory, language, visuospatial skills, abstraction, calculation and orientation. It is widely used
around the world and is translated to 36 languages and dialects.2. Cognitive Domains assessed by the MoCA
Visuospatial/Executive
Modified Trail Making Test
Beside visuomotor and visuoperceptual skills, the trail making test-B (TMT-B) requires mental flexibility to shift
between numbers and letters which mainly rely on frontal lobe function (2-5). In functional Magnetic Resonance
Imaging (fMRI) studies, shifting ability in the TMT-B revealed greater activation relative to the trail making test A
Copy of the Cube
The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
To copy a cube, subjects have to initially convert a two-dimensional contour to a three-dimensional cube. This
ability is enhanced by learning experiences(12,13). After spatial planning, visuomotor coordination also plays a role
in copying the cube. Various brain areas are involved; visual perception in the parieto-occipital lobe, planning in the
frontal lobe, and integration of visual and fine motor sequences in the fronto-parieto-occipital cortices.
The cognitive mechanisms underlying performance in copying a figure are different according to the underlying
disease. Alzheimer's disease (AD) patients with spatial perception/attention impairment had significant atrophy in
the right parietal cortex. Complex two-dimensional figure copy were negatively associated with degree of right
inferior temporal atrophy and reduction of cerebral blood flow in the right parietal cortex (14,15). Patients with
behavioral variant fronto-temporal dementia had spatial planning and working memory dysfunction had significant
atrophy in the right dorsolateral prefrontal cortex (16). A correlation between neuro-imaging and cube copying
specifically, has not yet been reported.Even though, a high proportion of either normal subjects (40%) or Alzheimer patients (76%) performed poorly on
cube drawing on verbal command, persistent failure to copy a cube from a previously drawn cube is highly
discriminative to detect patients with Alzheimer's disease (17). Less educated, older age, female and depressed
subjects performed poorly in drawing-to-command and copying conditions.The Clock Drawing Test
The Clock Drawing Test (CDT) has been widely used and studied for detection of dementia and mild cognitive
impairment. Planning, conceptualization, and symbolic representation are involved in drawing a clock's face and in
placing all the numbers correctly(18,19). Inhibitory response is required when placing each hand to tell the time of
"ten past eleven". Self-initiated-clock-drawing also requires intact visuoconstructive skills which are mainly
represented in the parietal lobe.In volunteers, fMRI demonstrated bilateral activation of the posterior parietal cortex and the dorsal premotor area
during task performance suggesting the contribution of the parieto-frontal cortical networks to integrate visuospatial
elements and motor control in self-initiated clock drawing(20).In AD patients, errors in CDT were mainly conceptual and due to semantic memory impairment (21-23). This was
supported by various neuroimaging studies that found negative correlation between CDT performance and atrophy
of the right/left temporal cortices (24,25), atrophy of the medial temporal lobe (23), reduction in the activation of the
left superior parietal lobe (26), and hypo metabolism of the right parietal cortex (27) in patients with cognitive
impairment caused by AD pathology.White matter hyperintensities (WMH) is also related to performance on CDT (23). Patients with severe WMH and
patients with Parkinson's disease (PD) performed poorly and similarly on all subscales of CDT(28). Even though
The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
both groups were different in term of neuropathology, they both have disrupted subcortico-frontal pathways. PD
affects the subcortical dopaminergic pathway projecting to the prefrontal cortex (28,29).The scoring criteria for the CDT in the MoCA has been simplified to decrease scoring complexity, scoring time, and
minimize inter rater variability.Despite the simpler scoring instructions, suboptimal inter and intra-rater reliability for MoCA's CDT were recently
reported(30). CDT may be influenced by literacy status and education level (21,31,32,33).Naming
"It lives in the desert (Camel)", this couldsuggest either word finding difficulty or semantic memory impairment. If subjects cannot tell both the name and the
context, they may have impaired visuoperceptual skills with inability to recognize the animal (failure in the cube
copy and the CDT can support this possibility). They may also be impaired in both visuoperception and semantic
memory such as in moderate to severe AD or advanced PD with dementia. Low education or cultural exposition to
such animals can also be responsible.In AD, impairment tend to reflect a breakdown in semantic processes which is different from visuoperceptual
deficits caused by subcortical dementia such as Huntington's disease (HD) (33).Some studies have shown that
semantic dysfunction is the primary cause of misnaming in both cortical or subcortical dementia (34,35).
The neuronal network involved in naming is category-dependent (36-39). In healthy subjects, the commonly
activated regions were bilateral occipital lobes including the fusiform gyrus, and pars triangularis of the left inferior
frontal gyrus (37-39). This activation pattern may be explained by processing of visual features and shape analysis,
in the primary visual cortex and fusiform gyrus, and the subsequent retrieval process from semantic and conceptual
knowledge of animals mediated by the pars triangularis of the left inferior frontal gyrus (39,40). Interestingly,
animal naming was also associated with activation of the frontal regions linked to the limbic emotional system such
as the left supplementary motor area and the anterior cingulate gyrus (37,38). It has also been shown that animal
naming is more associated to primary visual cortex activation than naming of tools which is associated with the
frontal and parietal lobe activation (premotor cortex and postcentral parietal cortex) (37).Attention
The Digit Span
The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
Digit Span Forward (DSF) measures retention of auditory stimuli and articulatory rehearsal. Digit span backward
(DSB) requires transient working memory, and more demanding ability in transforming digits into a reversed order
before articulating. This extra-step requires central executive processing (41).Neuronal networks involved in digit span processing have been shown in many neuroimaging studies. In healthy
subjects, using near-infrared spectroscopy (NIRS) a relationship between activation of the right dorsolateral
prefrontal cortex and performance on DSB was observed (42). Other studies have shown greater activation of the
bilateral dorsolateral prefrontal cortices, prefrontal cortex and left occipital visual regions for DSB compared to
DSF (41-44). These findings confirm the need for executive function to complete the DSB task. Activation of the
visual cortex during DSB supports the hypothesis that visuospatial processing may be involved during mental
reversal imaging of digit sequences (42,43).Amnestic Mild Cognitive Impairment (MCI) and AD patients performed poorly on both tasks compared with normal
controls (45-47). PD patients with amnestic MCI had some impairment in DSB, but not DSF (48). Early impairment
of executive function caused by subcortico-frontal dopaminergic dysfunction explains the isolated poor performance
on DSB among PD patients. At the cutoff <3 digits, the sensitivity and specificity of DSB in detection of major
cognitive disorders (including dementia, delirium and cognitive impairment not otherwise specified) are 77% and
78%, respectively (49). With the same cutoff, DSB can detect 81% of the delirium patients, however, with false
positive rate of 37% (49). Moreover, impaired digit span in elderly subjects with subjective memory complaints is a
predictor for the conversion from subjective memory complaints to mild cognitive impairment (50).Concentration and Calculation
Letter A tapping test
Concentration, which is defined as sustained and focused attention, is the primary function required for proper
identification of letter A and inhibition of inappropriate non-letter A tapping. It has good sensitivity to cognitive
impairment in mild traumatic brain injury and persistent post-concussion syndrome (51,52). Speed of response to
externally-paced stimuli accounts for this test's sensitivity (52). This task has not been well studied in
neurodegenerative diseases. In the MoCA validation study, MCI subjects and Normal Controls had comparable
normal performance, however, AD subjects were significantly more impaired on this task.(1)Serial 7 subtractions
Calculation is an essential part of everyday social and living activities. In normal subjects, bilateral parietal and
prefrontal cortices have been reported to be consistently activated during mental calculation, along with left inferior
frontal lobe and angular gyrus activation (53-57). Some studies suggest that the linguistic representation and
visuospatial imaginary also play a role in mental calculation (54,58). Specific to serial 7 subtraction, fMRI had
The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
reported similar greater activation in the bilateral premotor, the posterior parietal and the prefrontal cortices when
normal participants performed this task compared with the control condition (59). The prefrontal cortex activation is
associated with working memory which is required to maintain the previous answer in a loop for further
subtractions.In AD patients, a reduction of fMRI activation or PET glucose metabolism in the inferior parietal cortex was
observed during mental calculation (53,60). Some studies also reported a reduction in activation in the bilateral
lateral prefrontal cortices (53), and the left inferior temporal gyrus (60). These hypofunctional areas are the same as
the ones reported being significantly activated in normal subjects.Language
Sentence Repetition
Sentence repetition assesses language skills which are supported by left temporo-parietal-frontal circuit. Repeating
complex sentences also requires attention and concentration to memorize the words which are supported by working
memory systems in the frontal lobes (61). AD patients had lower scores on this task compared with normal
subjects(1,61,62). Education also plays a role in sentence repetition, and interpretation of the results should take into
consideration subjects' education level (63).Letter F fluency
Verbal fluency is divided into phonemic (letter) and semantic (category) fluency. Letter F fluency in the MoCA
mainly depends on frontal lobe function compared with semantic fluency, which is sustained by both temporal and
frontal lobes. Letter F fluency requires coordination of lexicosemantic knowledge, shifting from word to word,
working memory, searching strategy and inhibition of irrelevant words which all highly depend on frontal lobe
function and to a lesser extent the temporal lobe.Patients with frontal lesions produced fewer words than healthy controls(64-67). Left frontal lesions play a greater
role in letter fluency impairment than right frontal lesions(64,67,68). However, specificity of the frontal lobe
dysfunction to letter fluency impairment is still debated as patients with non-frontal left hemisphere lesions also
performed worse than patients with right hemisphere frontal and non-frontal lesions(67).Neuroimaging studies indicate that letter fluency activates a variety of frontal (left dorsolateral prefrontal cortex, left
inferior frontal gyrus, supplementary motor area) and non-frontal areas (anterior cingulate cortex, bilateral temporal
and parietal lobes (69-71). Both lesional and neuroimaging studies suggest high sensitivity of the test, but low
specificity, to detect frontal lobe dysfunction (72). Low specificity may partly depend on education level and
literacy status, as this task requires grapheme-phoneme correspondence. Lower educated and illiterate subjects
The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
generate fewer words than subjects with higher education (73-75). Since letters do not exist in certain languages,
letter fluency was replaced by semantic fluency (animal naming) for languages such as Chinese, Korean, in the
MoCA test (76,77).
As phonemic fluency is highly associated with frontal executive function, pathologies affecting frontal lobe or
fronto-subcortical circuits, such as in PD and HD patients, frequently impair this function more than lesions of the
temporo-parietal lobe which are associated with storage of lexicosemantic knowledge (48,78-80). In contrast,
patients with Alzheimer's pathology will more likely have semantic fluency impairment early in the course of their
disease (81). Patients with depression have also impaired phonemic fluency as a result of probable overall global
cognitive slowing (82).Abstraction
The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
PD patients still had impairment in recognition (94,95). Retrieval memory deficits can also be seen in Depression
(96,97), Frontotemporal Dementia (98,99), Normal Pressure Hydrocephalus (100), and HIV Cognitive Impairment
(101,102).Encoding memory impairment correlates with hippocampal atrophy and hypometabolism (86,87,103). AD patients
typically perform poorly on delayed free recall without improvement after cueing, and also have higher rates of
intrusion compared with PD and HD patients (104). Encoding memory deficits are also seen in Wernicke and
Korsakoff syndromes, strategically located ischemic or hemorrhagic strokes or tumors that affect the Papez circuit
(Hippocampus, fornix, Mamillary bodies, Thalamus, and Cingulate cortex), and post surgical excision of the Medial
Temporal lobes for Epilepsy control as first described in H.M. by Milner (105-107).Orientation
Impairment in orientation has been shown to be the single best independent predictor of daily functions in patients
with dementia, and is also associated with caregiver burden and psychological distress (108,109). Temporal
orientation yields high sensitivity in detection of dementia and patients with delirium. Errors in identifying the date
has the highest sensitivity (95%), but also lowest specificity (38%) (110). Identification of the year or month was
suggested to detect cognitively impaired subjects with optimal validity(110). However, orientation is not a good
indicator to detect milder stages of cognitive impairment(1). Temporal orientation can also predict overall cognitive
decline over time (111). Moreover, patients with temporal disorientation tend to be impaired on verbal memory as
well (112). Orientation to place is not discriminative in milder stages of cognitive impairment and dementia, but
may be able to detect very severe cognitive impairment which is also obvious without cognitive screening.
3. MoCA Development and Validation
The MoCA (Copyright: Z. Nasreddine MD) was developed based on the clinical intuition of one of the authors of
the validation study (ZN) regarding domains of impairment commonly encountered in MCI and best adapted to a
screening test (1). An initial version covered 10 cognitive domains using rapid, sensitive, and easy-to-administer
cognitive tasks. Iterative modification of the MoCA took place over 5 years of clinical use. An initial test version
was administered to 46 consecutive patients (mostly diagnosed with MCI or AD) presenting to the Neuro Rive-Sud
(NRS) community memory clinic with cognitive complaints, a MMSE score of 24 or higher, and impairedneuropsychological assessment. They were compared with 46 healthy controls from the same community with
normal neuropsychological performance. Five items did not discriminate well and were replaced. Scoring was then
adjusted, giving increased weight to the most discriminant items. The final revised version of the MoCA (version
7.1) covers eight cognitive domains and underwent a validation study at the Neuro Rive-Sud (NRS) community
memory clinic on the south-shore of Montreal and the Jewish General Hospital memory clinic in Montreal (1).
Participants were both English and French speaking subjects divided into three groups based on cognitive status;
normal control (n=90), Mild Cognitive Impairment (n=94), and mild Alzheimer's disease (n=93). MoCA was
The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
administered to all groups, and its sensitivity and specificity were compared with those of the MMSE for detection
of MCI and mild AD.Optimal cutoff scores
Sensitivity was calculated separately for the MCI and AD groups. One point was added to the total MoCA score to
correct for education effect for subjects with 12 years or less education. The MoCA exhibited excellent sensitivity in
identifying MCI and AD (90% and 100%, respectively). In contrast, the sensitivity of the MMSE was poor (18%
and 78%, respectively). Specificity was defined as the percentage of NCs that scored at or above the cutoff score of
26. The MMSE had excellent specificity, correctly identifying 100% of the NCs. The MoCA had very good to
excellent specificity (87%). When MMSE and MoCA scores were plotted together (Figure 1), the large majority of
NC participants scored in the normal range, and the large majority of AD patients scored in the abnormal range on
both MMSE and MoCA. In contrast, 73% of MCI participants scored in the abnormal range on the MoCA but in the
normal range on the MMSE(1).The test-retest reliability was 0.92. The internal consistency of the MoCA was good with a Cronbach alpha on the
standardized items of 0.83(1). In addition, the positive and negative predictive values for the MoCA were excellent
for MCI (89% and 91%, respectively) and mild AD (89% and 100%, respectively).Recommendations
The Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD3)recommended administering the MoCA to subjects suspected to be cognitively impaired who perform in the normal
range on the MMSE (113). Immediate and Delayed recall, Orientation, and letter F fluency subtest of the MoCA
have been proposed by the National Institute for Neurological Disorders and Stroke (NINDS) and the Canadian
Stroke Network (CSN) to be a 5-minute Vascular Cognitive Impairment screening test administrable by telephone
(114). The MoCA has also been recommended for MCI or Dementia screening in review articles (115-117).
Figure 1: Scatter plot of the Montreal Cognitive
Assessment (MoCA) and the Mini-mental State
Examination (MMSE) scores for normal controls (NC) and subjects with Mild Cognitive Impairment (MCI) and mild The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
It is important to emphasize that MoCA is a cognitive screening instrument and not a diagnostic tool, hence clinical
judgment, based on thorough clinical evaluation, is important in interpreting MoCA test results and correctly
diagnosing patients who present with cognitive complaints. Figure 2 illustrates a practical approach to evaluate
patients with cognitive complaints. Patients presenting with cognitive complaints and no functional impairment in
their activities of Daily living (ADL) would be better assessed by the MoCA as first cognitive screening test.
Subjects presenting with cognitive complaints and ADL impairment would probably better assessed by the MMSE
first, then the MoCA if the MMSE is in the normal range.4. Demographic effect on MoCA performance
Education has been consistently reported affecting total MoCA scores (1,76,118-123). Trail making test and digit
span of the Japanese version of the MoCA significantly correlate with years of schooling (124). The cube copy,
semantic fluency (substitution of letter F fluency), abstraction, serial-7 subtraction and naming in the Korean version
of the MoCA positively correlated with education (77). There are many cutoff scores reported according to the level
of education of the studied population. In general, studies recruiting a higher proportion of low educated subjects
recommend lower cutoff scores for the education correction.MoCA has been shown to be age (76,119,121,122) and gender independent (76,119,121-123). However, in a large
normative study in USA, age negatively correlated with MoCA scores. Upon further analysis, age was a significant
Figure 2: Practical approach to evaluate patients who present with cognitive complaints, adapted from Nasreddine et al. (2005) (1). ADL= Activities of Daily Living. NPV= Negative Predictive Value. PPV=PositivePredictive Value. MCI=Mild Cognitive Impairment
with impaired ADL 25DEMENTIA
(sensitivity 78%) 25DEMENTIA
(sensitivity 100%,PPV 89%) DEMENTIA unlikely
(specificity 87%, NPV 100%) reevaluate functional status and other causes of cognitive complaints with intact ADL 25MCI (sensitivity 90%,
PPV 89%
COGNITIVELY
INTACT
(specificity 87%,NPV 91%)
The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
factor in MoCA scores mostly for less educated subjects (123) which could be explained by low cognitive reserve
among less educated individuals which may result in lessened ability to recruit neuronal network and compensate
age-related cognitive changes. Moreover, lower educated subjects are known to have more vascular risk factors that
could also impair their cognition (125).5. Mild Cognitive Impairment (MCI) and Alzheimer's Disease (AD)
The MoCA was extensively studied as a screening tool for detection of MCI and Alzheimer Disease. Sensitivity
for MCI detection was on average 86% (Range 77%- 96%). Sensitivity to detect AD was on average 97%(Range 88-100%). Specificity defined as correctly identifying Normal Controls, was on average 88% (Range
Table 1 summarizes the MoCA validation in MCI and AD in diverse populations and languages.Variability in sensitivity and specificity is explainable by differences in selection criteria for normal controls,
diagnostic criteria for MCI and AD, community or memory clinic setting, confirmation with neuropsychological
battery, age and education levels, and possibly linguistic and cultural factors.Table 1: MoCA studies in MCI and AD
0.80 0.80 0.80 0.80
1.00 0.98 0.98 1.00
412 years of education
(epsilon) 1 additional point for subjects who have 6 years of education The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
(delta) validity cannot be fully assessed due to lack of normal control groupAD = Alzheimer's disease; aMCI = amnestic Mild Cognitive Impairment; Dem = Dementia; MCC = Memory Clinic Controls with other
diagnosis than dementia, NC = Normal controls; ODD = Other dementia diseases Sn = sensitivity; Sp = specificity; PPV = positive predictive value; NPV = negative predictive value6. Vascular Cognitive Impairment (VCI)
Multiple studies have addressed the usefulness of the MoCA in Vascular Cognitive Impairment (See Table 2).
A. Asymptomatic cerebrovascular disease patients with vascular risk factorsThe MoCA has been shown to detect cognitive decline in asymptomatic subjects with hypertension alone, or
thickening of the carotid artery wall, or multiple vascular risk factors (134,135). Cognitive decline was also detected
in subjects with TIA or first ever stroke if they had more than two vascular risk factors or low cerebral perfusion on
transcranial Doppler ultrasound (134,135). MoCA also correlated with the Framingham coronary and stoke risk
scores (136).Advanced internal carotid artery stenosis (>70%)/occlusion is also negatively correlated with MoCA but not
MMSE scores in asymptomatic subjects (137,138).
Subtle cognitive impairment among subjects from cardiac and diabetic/endocrine outpatient clinics of tertiary-
referral hospital were detected using the MoCA with sensitivity of 83-100%, but with lower specificity of 50-52%
(139).B. Symptomatic cardio-vascular disease
Cognitive Impairment Post-stroke or TIA
The MoCA has been shown to detect cognitive impairment in 65% of subjects 3 months post-stroke (140). Also 30
to 58% of subjects with TIA or stroke who were considered normal on the MMSE scored below the normal cut-off
on the MoCA ranging from 14 days to up to 5 years after the event (146, 148). See Table 2 for a summary of studies
of the MoCA for vascular cognitive impairment. Another study, using Neuropsychological assessment as gold
standard, found that MoCA had a sensitivity of 67%, and a specificity of 90% for detection of cognitive impairment
post acute stroke (156). In this study, the neuropsychological battery was not performed at the same time as the
MoCA (24 versus 7 days respectively) which could explain significant differences in sensitivity and specificity
compared to other studies, and the MoCA cut-off used was MoCA 20 (158).Heart failure
The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
54% to 70% of non-demented community-dwelling adults with heart failure (HF) (ejection fraction 37-40%) had
low cognitive scores on the MoCA (26) (149, 150). Reduction in ejection fraction and various associated vascular
risk factors such as hypertension, dyslipidemia or diabetes mellitus may contribute to chronic reduction of cerebral
blood flow in HF patients (145-147).Sub-optimal self-care and functional dependency
MoCA identified MCI in patients with heart failure that had suboptimal self-care behaviors (148).Using the MoCA as a cognitive assessment instrument, the self-rated version of the instrumental activities of daily
living (IADL) scale was administered to evaluate functional dependence among 219 non-demented patients with
cardiovascular diseases and risk factors (149). MCI was diagnosed when MoCA was less than 23/30. Less
dependence was associated with higher MoCA scores, and a person who scored in the MCI range was 7.7 times
more likely to report need for assistance with 1 or more activity of daily living. This study indicated that subtle
cognitive impairment was an independent predictor of functional status in patient with cardiovascular disease (149).
Cerebral small vessel disease
MoCA was shown to be sensitive to white matter disease and a history of stroke, detecting cognitive impairment
with a sensitivity of 73% and specificity of 75% (77, 155).Subcortical ischemic vascular dementia (SIVD)
Subcortical ischemic vascular injury has been proposed to be associated with cognitive impairment as a result of
neuronal circuit disconnection between subcortical regions, frontal cortex and other cerebral regions following
repeated silent subcortical injuries (150-153). Vascular dementia was also detected by the MoCA with a sensitivity
of 86.8% and specificity of 92.9% (121).Monitoring of treatment
Cognitive outcomes after undergoing carotid endarterectomy (CEA) in severe unilateral internal carotid artery
stenosis were studied using MoCA and MMSE as primary outcome measures. Symptomatic carotid stenosis (SCS)
and asymptomatic severe carotid stenosis 60% (ACS) patients with the age- and sex-matched control subjects who
underwent laparoscopic cholecystectomy (LC) were compared. At baseline, the SCS group, but not the ACS, was
significantly more impaired on the MoCA and MMSE total scores compared with the LC group. Postoperatively,
only the SCS patients had significant improvement on both tests when comparing pre-operative and 12-month post-
operative performance (154). The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
Table 2: MoCA Studies in Vascular Cognitive ImpairmentFirst Author (year)
Martini-Popovi
(2006,(134);2007, (135))
Croatian To assess subtle cognitive
decline in patients with first ever cerebrovascular disease (CVD) and in subjects withoutCVD symptoms but with CVD
risk factors (CV-RF) CVD (N=81 (134) & 110 (135)) CV-RF (N=45) The MoCA provided superior sensitivity than the MMSE in detection of MCI in CVD and CV-RF patients , the sensitivity and specificity to detect of -Popovi 21).The visuospatial/executive function, attention and delayed recall subtest of the MoCA provided a good discriminative power.
27) had abnormal
26., the MoCA sensitivity to detect of aMCI &
26 on the MoCA, whereas, only
2.2% scored < 24 on the MMSE. Delayed recall,
visuospatial/executive function and language subtest of theMoCA were impaired in more than 60% of patients.
(epsilon) 1 additional point for subjects who have 6 years of education (star) The score adjustment method according to age and education is available in the article (142). (alpha)1 additional point for subjects who have 12 years of education
aMCI = amnestic mild cognitive impairment; mMCI=multi-domain mild cognitive impairment; NC = normal control; VaD = vascular dementia
PPV = positive predictive value; NPV = negative predictive value The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
7. Parkinson's Disease (PD)
The prevalence of dementia in PD is between 20-40% (157). The early cognitive changes are mediated by fronto-
striatal disconnection, such as executive function and attention (158). Single domain impairment is found more
frequently than multiple domain deficits in early stage (158,159). Progression of PD affects other cognitive domains
such as memory (157,160). The association between cognitive impairment and cholinergic denervation & frontostriatal dopaminergic deficits among PD and PD with dementia (PDD) has been demonstrated byneuroimaging studies (161,162). Detection of cognitive impairment in PD is clinically useful as it predicts the
conversion to PDD (160), contributes to caregiver's distress (163), and guides timing to initiate cognitive enhancing
treatment (164).The MoCA has an adequate sensitivity as a screening tool for detection of PD-MCI or PDD in a clinical setting,
based on diagnostic criteria and neuropsychological test batteries (165,166). Half of PD patients with normal age
and education-adjusted MMSE scores were cognitively impaired according to the recommended MoCA cutoff
(25/26) (167,168) as it lacks a ceiling (165,169,170). Sensitivity and specificity for PDD were 81-82% and 75-95%
respectively. Sensitivity and specificity for PD-MCI are 83-90% and 53-75% respectively (166).Baseline MoCA scores predicted the rate of cognitive deterioration among PD patients. The group of rapid decliners
had lower scores on total MoCA score, clock drawing, attention, verbal fluency and abstraction subtest when
compared with slow decliners (171).Table 3: MoCA in Parkinson's disease (PD)
First Author
Gill The Montreal Cognitive Assessment (MoCA): Concept and Clinical Review Authors: Parunyou Julayanont, Natalie Phillips, Howard Chertkow, and Ziad NasreddineVersion: February 18, 2012
Hoops et al.
, the MoCA provided sensitivity of 0.83 and , the MoCA provided sensitivity of 0.82 and , the MoCA provided sensitivity of 0.90 and , the MoCA provided sensitivity of 0.81 and , the MoCA provided sensitivity of 0.90 and if the MoCA or FAB or ACE-R as screening tools if + a (alpha)1 additional point for subjects who have 12 years of education
PD-N = cognitively normal Parkinson's disease; PD-MCI = mild cognitive impairment Parkinson's disease; PDD = Parkinson's disease with
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